Pills and Money
Issue Background

Oral Anticancer Treatment Access Legislation

The IMF believes that all cancer patients should have access to the treatment recommended by their physicians and should not suffer from cost discrimination based on the type of therapy provided or the mechanism for the delivery of that therapy. 

Outdated Health Insurance Policies Limit Patients’ Access to New Lifesaving Drugs

Advances in cancer treatment are saving lives and cutting health-care costs; however, insurance coverage has not kept pace with innovation in medicine and the growing trend towards orally and other patient administered anticancer treatments. Traditionally, intravenous (IV) treatments have been the primary route for administering life-saving anticancer drug therapy. Today, patient administered treatment has become more prevalent and is the standard of care for many types of cancer.

Unfortunately, insurance plan design has not kept up with medical innovation at the expense of the care doctors can provide to patients. Current insurance plan design allows for IV treatments to be covered as a medical benefit with a relatively small co-payment.  But, because newer oral cancer drugs are covered as a pharmacy benefit, patients can be charged up to 50 percent of the cost, even if they are the only treatment that will work.

While oral therapies have been available for decades, the past 10 years has seen accelerated development of oral anticancer drugs so that more than 35% of the oncology development pipeline is oral therapies.  These pills are not only less toxic than conventional IV chemotherapy, but they have turned once-incurable cancers such as myeloma into manageable diseases. More importantly, many oral anticancer medications do not have IV or injected alternatives and are the only option for some cancer patients.

As these medications become more prevalent in cancer treatment, they must be as affordable as their IV counterparts. Since patient administered anticancer medications are often covered under a health plan’s prescription benefit, many patients are responsible for extremely high and unmanageable co-pays. These co-pays can be hundreds or thousands of dollars per month and, as a result, almost 10% of patients choose not to fill their initial prescriptions for oral anticancer medications.

This is important for myeloma patients because there have been several recent FDA approvals in myeloma -- most of which are oral medications. Below Meghan Buzby, Senior Director of Advocacy for the IMF, explains that insurance reimbursement issues can create high out-of-pocket costs for patients and describes what the IMF is doing to fix this problem.